Study of the infections in the male genital Arabia

Brief Communication
Study of the infections in the male genital
system in the western region of Saudi
Arabia
Faten S. Gazzaz, MSC, PhD,
Hisham A. Mosli, MD, FRCSC.
P
rostate diseases as benign prostatic hyperplasia
(BPH), chronic prostatitis and erectile dysfunction
are a major worldwide male health problem affecting men
during their lifetime. It is accepted that inflammation
especially that is due to infections has a role in prostate
diseases and it could stimulate carcinogenesis probably
by causing genome damage enhancing cell replication.1
Association of sexually transmitted diseases (STD) with
the development of prostate cancer specifically human
papillomavirus (HPV) and Neisseria gonorrhoeae was
studied as a possible risk factor. Pathogens infecting
the male genital area may induce either symptomatic
or asymptomatic chronic prostatic inflammation that
could be an important factor in the development of
prostatitis, BPH, and prostate cancer. Multiple sexual
partners with unprotected sex increase risk of STD as
Syphilis and Gonorrhea, which may produce a sexually
transmissible factor that increases the risk of prostate
cancer. There are several aspects that require further
investigation to properly define, characterize, and
categorize prostatitis.2 Skerk et al2 found Chlamydia
trachomatis (C. trachomatis), Trichomonas vaginalis
(T. vaginalis), Escherichia coli (E. coli), Enterococci,
Proteus mirabilis, Klebsiella pneumoniae, Streptococcus
Agalactica (Strept. agalactica), Ureaplasma urealyticum in
patients with chronic prostatitis. The Centers for Disease
Control (CDC) suggested STD treatment guidelines
and recommend inclusion of Trichomonas therapy for
men with recurrent non-gonococcal urethritis (NGU).
Persistent NGU and prostatitis due to T. vaginalis
was described by Abdolrasouli et al3 proving
the importance of the laboratory diagnosis of
Trichomoniasis in persistent or recurrent urethritis. Sherk et al4 studied again the etiology and the role of
unusual pathogens in chronic prostatitis syndromechronic bacterial prostatitis, and inflammatory as well
as non-inflammatory chronic pelvic pain syndrome
suggested that many patients with inflammatory as
Disclosure. This study was funded by the Deanship of
Scientific Research (DSR), King Abdul-Aziz University,
Jeddah, Kingdom of Saudi Arabia (Research Project No.
05-026/430).
well as non-inflammatory pelvic pain syndrome may
have unusual pathogens as C. Trachomatis, Ureaplasma
urealyticum, Mycoplasma hominis (Mh) and T. vaginalis
in their prostate as suggested in many the literature.
Infection of the testis and prostate is implicated in a
deterioration of sperm, possibly affecting fertility. The
difficulty arises because the male reproductive tract
is an immune-privileged site that can be disrupted,
potentially affecting spermatogenesis, if inappropriate
inflammatory responses are provoked.
The objective of this study was to identify and report
the pattern of sexually transmitted infections in random
male subjects in Jeddah, Saudi Arabia.
In order to accomplish this goal among other
screening services freely provided to males in our
community, men were invited to voluntarily attend
a men’s health screening clinic set at King Abdulaziz
University Hospital, Jeddah, Saudi Arabia; public
advertisements were placed for this purpose. During a
10 month period from April 2010 to February 2011,
volunteers aged (19-70 years) underwent systematic
clinical urogenital evaluation, who also provided male
urethral swabs. All participants enrolled signed an
informed consent form as required by the Hospital
Medical Ethics Committee.
The design of the particular laboratory screening of
specimens focused on the detection of a wide range of
sexually transmitted organisms including C. trachomatis,
Ureaplasma urealyticum, Mycoplasma hominis, Herpes
simplex (HSV), Cytomegalovirus (CMV), HPV, Candida
albicans, Neisseria gonorrhoeae, T. vaginalis, E. coli,
Proteus mirabilis, Klebsiella pneumonia, Enterococci and
Strept. agalactica.
Inclusion criteria were asymptomatic volunteer
males above 18 years with sexual exposure, those
complaining of either lower urinary tract symptoms
(LUTS) or urethral discharge or those presented
with ejaculation symptoms as painful or premature
ejaculation. Exclusion criterion was asymptomatic
young male <18 years of age.
A total of 882 specimens from 63 male subjects
with no evidence of structural or functional lower
genitourinary tract abnormalities were examined.
Specimens were collected by rotating swab in the male
urethra to contain as many epithelial cells as possible,
as some organisms as Chlamydia are intracellular and
infect epithelial surfaces. Specimens were collected,
transported and preserved in such a way as to maintain
the viability of organisms.
All specimens were cultured in cell lines (Human
foreskin (HFS) and green monkey (VERO) cell) to
test for the presence of HSV and CMV. Chlamydia
trachomatis5 was examined in urethral swab by culturing
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Male genital system infections … Gazzaz & Mosli
the samples in McCoy cells and then confirmed using
DAKO Immunofluorescent assay (IFA). The diagnosis
of urogenital Mycoplasma hominis and Ureaplasma
urealyticum and antimicrobial susceptibility were
performed by using Mycofast screening test from
International Microbio. Digene Hybrid Capture
2 (HC2) was used for the detection of HPV. The
specimen for HPV DNA was collected in Digene
Specimen Transport Medium (STM). Cultures and
bacterial identification were performed by using
standard microbiological methods on males urethral
discharge for the detection of Neisseria gonorrhoeae, T.
vaginalis, E. coli, Enterococci, Proteus mirabilis, Klebsiella
pneumoniae, Strept. agalactica, and Candida albicans.
Collected data were classified and analyzed by bar
charts graphic. The results obtained during the term of
the project using different tests, 18 men were considered
STD infected (Figure 1). Out of 63 males, 18 (28.6%)
were positive (Strept. agalactica were detected in 9
[14.3%], HPV in 4 [6.4%], Enterococci in 3 [4.8%],
Mycoplasma hominis in 1 [1.6 %], and Candida species
in 1 [1.6 %]. There were no cases of sexually transmitted
infections in 71% of the study group. The age average in
years according to each isolated organism is illustrated
in Figure 1.
Numerous reports have revealed a potential link
between chronic prostatic inflammation and multiple
types of prostate cancer.1-7 In order to study the previous
mentioned relation, we had first to evaluate the presence
of STD infections in some Saudi subjects, which was
the aim of the present study. Some data were published
regarding STD in Saudi Arabia, but was either for
limited organisms as Gonorrhea and Syphilis only as
in old work carried out by Pareek and Chowdhury.8 In
this study 716 men attending consecutively a dermato-
Figure 1 - Number of positive organisms in relation to average age of
male subjects at King Abdulaziz University Hospital, Jeddah,
Saudi Arabia.
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venereological clinic in Riyadh, Saudi Arabia, over
a period of one year, 70.1% had non-specific genital
infection, a figure which is 4 times that for gonorrhea
and 13 times that for syphilis. Most of the patients
were single men aged between 20 and 29 years and had
acquired their infections abroad. Retrospective studies
as in Madani9 getting information from Ministry of
Health (MOH) Archives and concluded that nongonococcal urethritis, trichomoniasis, and gonococcal
urethritis were the most commonly reported sexually
transmitted infections in Saudi Arabia. In other study
by Memish and Osoba10 concentrated on International
travelers who are at great risk of contracting any of
these STDs, including HIV, if they have been sexually
exposed to persons with any of these diseases. They
concluded that population movement has been shown
to be a major contributing factor in the global spread
of STDs. Increased sexual promiscuity and casual
sexual relationships tend to occur during travel abroad
to foreign countries. Travelers should be aware that
the risk of STDs is high and sexual encounter with
casual partners or commercial sex workers (CSWs)
carries a high risk of infection. Prevention of STDs
during travel can be achieved by complete abstinence
from sexual exposure. In a previously related study,
Mosli et al11 carried a prospective study on 63 patients
with idiopathic infertility and 23 male controls. They
indicated that there was a significantly higher incidence
of genital infection among male patients with idiopathic
infertility than in normal fertile controls who were not
infected or colonized with microbial agents (p=0.0004).
Ureaplasma urealyticum was isolated from 29 patients out
of the infected 40 (72.5%), Mycoplasma hominis from
11 patients (27.5%), Chlamydia from 10 (25%) and
bacteria from 9 patients only (22.5%). Three cases with
Group B streptococcal infection, one with hemophilus
para influenza, one with Group F streptococci, one
with Enterococci, 2 with Strept B-hemolytic and one
with Klebsiella pneumonia. Kelly et al5 suggested that
C. trachomatis is an etiological agent, with incidence of
up to 39.5% reported in patients with prostatitis while
no C. trachomatis was detected in the current study. The
Minnesota Department of Health (MDH)12 reported
in 2010 a total number of 17,760 STD cases where
15,294 are Chlamydia positive, 2,119 are gonorrhea
positive, 347 are Syphilis positive (all stages) and no
chancroid cases.12
The significance of Group B Strep infection (9
positive cases more frequently isolated in our study) is
illustrated as it colonized in the male urethra and could
cause sepsis and meningitis in neonates and young
infants of the female partner. It also causes other serious
infections, such as bacteremia and cellulitis, in nonpregnant adults with underlying medical conditions and
Male genital system infections … Gazzaz & Mosli
is transmitted vertically to the newborn during labor
and delivery. Among non-pregnant adults, transmission
occurs via direct contact; some studies suggest that
sexual transmission occurs. Four (6.45%) cases of HPV
infections is highly significant, as the males’ partners
are at risk to contact HPV infection and cancer of the
cervix as studies show that HPV DNA is found in high
percentage of cervical carcinomas and cells derived from
those cancers.4 Human Papillomavirus is a sexually
transmitted infections, yet previous study5 did not find
a single positive HPV tissue specimen obtained from
66 patients undergoing prostatic biopsy or resection13
while Gazzaz14 obtained 5 (5%) positive high risk
HPV in endocervical swabs. In our present study, one
(1.59%) case of Candida infection in a young healthy
male is not common (Figure 1). Fewer infections were
detected in the studied population. The most likely
explanation for this finding is either the fact that STD is
low in our country or more selective cases with sexually
transmitted infections signs and symptoms should
be tested. The number of subjects was smaller than
expected and that was due to the invasive procedure
to obtain the urethral specimens especially in normal
healthy subjects, however the wide spectrum of the
investigations and the number of the specimens was
substantially large. We suggest that more cases should
be included by selecting males based on the presence of
STD signs and symptoms or prostatic diseases. These
patients need help and will not refuse investigations. Sexual health awareness among Saudi married couples
is lacking. Even though the incidence of STIs in Saudi
Arabia is limited, appropriate preventive strategies that
follow the Islamic rules and values are essential and
should be of highest priority in community education
to avoid the potential of such infections to spread.
We hope that the results of this study on STD
pathogens could contribute to further clarification of
etiology of infectious prostatitis leading to prostate
cancer. We believe that sexually transmitted infections
are present in our community, but in a lower rate than
in Western countries.
Acknowledgment. We thank Mr. Sohail Malibary and Mrs.
Eman Taibah, Virologists, and Mr. Bassem Abualola, Microbiologist,
for processing of specimens.
Received 4th May 2011. Accepted 26th December 2011.
From the Department of Microbiology and Urology, King Abdulaziz University
Hospital, Jeddah, Kingdom of Saudi Arabia. Address correspondence and reprints
request to: Dr. Faten S. Gazzaz, Virology Laboratory, King Abdulaziz University
Hospital, PO Box 80215, Jeddah 21589, Kingdom of Saudi Arabia. Tel. +966
(2) 6408424. Fax. +966 (2) 6403975. E-mail: [email protected]
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